Top Banner
Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals
30

Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Jan 11, 2016

Download

Documents

Lee Montgomery
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colonoscopy; Surveillance Indications

SR Brown

Colorectal Surgeon

Sheffield Teaching Hospitals

Page 2: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colorectal cancer screening in high risk groups

Gut 2002;51(Suppl V)

Page 3: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.
Page 4: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Screening vs Surveillance

• Screening– Asymptomatic population

• Surveillance– Previous symptoms/high risk

Page 5: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

High risk groups

• Previous colorectal cancer

• Acromegaly

• Ureterosigmoidostomy

• Hereditary and Familial bowel cancer

• IBD

• Previous polyps

Page 6: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Aims

• To discuss salient aspects of guidelines

• To highlight recent developments in colonoscopic surveillance

Page 7: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colorectal cancer surveillance

Page 8: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colorectal cancer surveillance; aims

• Detect recurrence

• Diagnose and treat metachronous neoplasia

• Evaluate anastomosis

Page 9: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colorectal cancer surveillance

• ‘Incidence metachronous tumours 5-10%’

• Metachronous cancers – approx. 2%– Cochrane review 1.3% (18/1342)

• Metachronous adenomas– 22% (425/1923)

Page 10: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Colorectal cancer surveillance

• Synchronous/‘early’ metachronous cancers– 4%– 0.6% ‘missed’ due to incomplete colon exam

Page 11: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Familial cancer surveillance

Page 12: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Familial Cancer Summary

Family group Screening procedure

Age at initial screen Screening procedure and interval

2 FDR with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

1 FDR<45 yr with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

Page 13: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Lifetime risk of colorectal cancer

Risk Group Risk (of dying)

General population 1:50

Any family history 1:17

One affected relative <45 years

1:10

Two affected relatives 1:6

Houlston et al. 1970

Page 14: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Familial Cancer Summary

Family group Screening procedure

Age at initial screen Screening procedure and interval

2 FDR with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

1 FDR<45 yr with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

Page 15: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Chances of preventing death with screening colonoscopy

35 year old with FDR<45 years

• 1 in 25,000 people aged 30-39 develop colorectal cancer per year

• Relative risk = 5

• Risk of cancer = 1 in 5000 in per year

• Assume asymptomatic cancer dwell time of 3 years

• Chance of detecting cancer 1 in 1660

Page 16: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Familial Cancer Summary

Family group Screening procedure

Age at initial screen Screening procedure and interval

2 FDR with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

1 FDR<45 yr with CRC

Colonoscopy

At 1st consult or age 35-40 years (whichever later)

If initial clear repeat at age 55

Page 17: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Chances of preventing death with screening colonoscopy

55 year old with FDR<45 years

• 1 in 1,630 people aged 50-59 develop colorectal cancer per year

• Relative risk = 3

• Risk of cancer = 1 in 543 per year

• Assume asymptomatic cancer dwell time of 3 years

• Chance of detecting cancer 1 in 181

Page 18: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Hereditary cancer surveillance

Page 19: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Hereditary Cancer Summary

Family group Screening procedure

Age at initial screen

Screening procedure and interval

FAP Genetic testing Flexi sig+OGD

Puberty Flexi sig yearly

Colectomy if +ve

HNPCC Colonoscopy +/- OGD

25 yrs or 5 yrs before earliest CRC in family

2 yearly colonoscopy and OGD

Juvenile polyposis

Peutz-Jegher

Genetic testing

Colonoscopy + OGD

Puberty Flexi sig yearly

Colectomy if +ve

Page 20: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

IBD surveillance

Page 21: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

IBD Summary

Disease group Screening procedure

Age at initial screen Screening procedure and interval

UC or Crohn’s coloitis

Colonoscopy+ biopsies every 10cm

After 8 years for pan colitis, 15 years for left sided colitis

3 yrly 2nd decade, 2yrly 3rd decade, yrly thereafter

UC + PSC Colonoscopy

At diagnosis PSC Annually

Page 22: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Controversies

• ? Survival advantage (Cochrane review 2004)– No clear evidence – May allow earlier detection of cancer– ?lead-time bias

Page 23: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Controversies

• Ongoing inflammation increases risk

• Dysplasia as a marker for cancer– Reliability– Detection– Histological interpretation

Page 24: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Controversies;detection

• Pan-chromoscopy and targeted biopsy (Rutter 2004)– Back-to-back colonoscopy– Conventional then dye-spray– Conventional no dysplasia in 2904 random

biopsies– Targeted 157 biopsies 7 patients with dysplasia

Page 25: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Ileo-anal pouch surveillance

Page 26: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Pouch cancer

• 15 case reports – 10 residual rectal mucosa– 5 ??pouch mucosa– All pre-existing dysplasia– 8 had cancer in original resection– 9 had mucosectomy

Page 27: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Surveillance recommendations

• Pouchoscopy

• 1st year then 2-3 yearly

• Increased surveillance (yearly) if– Pre-existing dysplasia/cancer– PSC

• Mucosectomy if high risk

Page 28: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Polyp surveillance

Page 29: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.
Page 30: Colonoscopy; Surveillance Indications SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.

Summary

• Read guidelines!!